62. We have given careful consideration to the administrative proposals to which the Home Office invited our attention, and to others which witnesses have suggested, or which have occurred to us in the course of our deliberations. as an essential preliminary to this section of our Report, we desire to emphasise the importance in the prevention of addiction of the administrative measures which preclude the importation, manufacture, sale and distribution of dangerous drugs by unauthorised persons, and regulate the procedure of those who are authorised. The administrative measures to which we refer in the following paragraphs relate more particularly to cases in which medical practitioners are concerned, as those upon whom the responsibility for distribution ultimately rests.
CONTROL OF SUPPLY AND PRESCRIBING.
69. Among the most important, and most difficult, of the matters thus requiring attention is that of the administrative action which should be taken in cases in which there is reason to think that a medical. practitioner may be supplying or ordering the drugs otherwise than for medical purposes, properly so called. The question of irregularity in prescribing raises issues, under the Regulations, that are somewhat different from those affecting supply, and it is to "supply" that the immediately succeeding paragraphs relate.
Questions of Apparently Improper Supply.
64. The cases, for consideration may arise in connection with (i) administration or supply to other persons or (ii) administration by the practitioner to himself
These two groups of cases are consistently considered seperately
65. As explained in Section I of this Report (para 6) the drugs to which the Dangerous Drugs Acts relate cannot be possessed by any person not authorised by the Home Secretary for the purpose except, where they are supplied or prescribed by a registered medical practitioner (or in certain cases by registered dentists or registered veterinary surgeons). Further, the drugs cannot be supplied except by a person so authorised. Registered medical practitioners have a general authority to possess or supply the drugs so far only as is necessary for the practice of their profession.
66. This general authority; to supply and posses may be withdeawn at the discretion of the Home Secretary from individual practitioners who have been convicted of offences under the Dangerous Drugs Acts, but as the Regulations stand at present, withdrawal of authorisation must be preceded by a conviction in the police court.
We have been asked to consider the advisability of such modification of the Regulations as would dispense with the necessity for police court action in cases in which the Home Secretary was advised by a suitably constituted Medical Tribunal that the authorisation of a medical practitioner to posess; and supply might properly be withdrawn.
67. We are of opinion that this proposal offers several advantages, both administratively and from the point of view of the medical profession. It is undesirable, in our view, that where it can be clearly shown that, for the public protection, the authorisation of a practitioner should be withdrawn, it should be necessary for the. Home Secretary to take the case to the police court in order to obtain a conviction. We are satisfied that there are many cases which would be adequately met by the withdrawal of the authorisation, without recourse to those penalties of fine and imprisonment which the magistrates have the power to inflict. These penalties we are informed by the Home Office, are in the majority of cases neither necessary nor desired. Further, consideration must be given to the public odium of a criminal trial and conviction which is specially felt when the prosecution takes place in the district in which the doctor practices.
68. Again, it is to be observed that the issue in such cases is essentially medical, namely, whether there was, or was not, justification fot the administration of the drugs in question. A Medical Tribunal would have obvious qualifications for the investigation of such questions which cannot be possessed by lay magistrates, acting without medical assistance other than that of such medical witnesses as they may hear.
69. Also it would in our opinion be advantageous that all cases in England and Wales should be dealt with by one Tribunal., and that there should similarly be one Tribunal to deal with all cases in Scotland; these Tribunals would thus acquire special experience, and be able to apply a uniform standard of judgement.
70. On these grounds we have no hesitation in recommending that the suggested change be made in the Regulations affecting the Home Secretary's power of withdrawal from medical practitioners of the authorisation to possess and supply Dangerous Drugs.
71. We assume that the cases referred to the Medical Tribunal would be confined to those which involved the question of whether the drugs had been supplied, administred or prescribed for other than legitimate medical purposes.
72. After considering various possibilities, we have come to the conclusion that the most suitable Tribunal would be one composed of some medical members, with a legal assesor, and that representative medical bodies should be responsible for the nominations of the medical members.
73. We suggest that, as regards England and Wales, one medical member should be appointed on the nomination of the general Medical Council, one on the nomination of the Royal College of Physicians of London, and one on the nomination of the British Medical association. In Scotland nominations might be made by the General Medical council, the Royal College of Physicians of Edinburgh, and the British Medical Association. It appears to as that the Legal Assessor to
the General Medical Council might properly be appointed Legal assessor
to the Tribunals.
74. In the case of those medical practitionere who are themselves addicted to the abuse of drugs, and whose authority to be in possession of the drugs needs consideration on account of apparently improper use in self-administration, the reasons for reference of the issue to such a Tribinal are in some respects even stronger than in cases of adminisration to others, It will be generally agreed that such practitionere are a source of special danger to the community, and their cases are usually such that avoidance, if possible, of police court, proceedings is particularly desirable. Moreover, the withdrawal of the authorisation to possess the drugs is specially valuable in the interest of the practitioner himself.
75, We consider, therefore, that a Medical Tribunal consituted on the lines listed above would afford valuable assistance to the Home Office in securing that possession and supply of the drugs by medical practitioners was restricted to that required for legitimate medical purposes, and would enable the Department to deal effectively, and in a manner satisfactory to the medical profession, with cases in which there were strong grounds for believing that a doctor was administering drugs for illegitimate purposes either to himself or to others.
Limitation of Prescribing .
76. We have reserved for seperate consideration the question of measures for dealing with improper prescribing, as distinct from "supply" In the fsrrst place, as has been pointed out in Section I of this Report (para. 17), doubts have arisen whether, under the presenet Regulations, prescribing of the druge is restricted, as are possession and supply to such as is necessary for medical purposes. Such a restriction of prescribing would be in accordance with the given intention of the Acts. Under the Dangerous Drugs Acts a prescription consitutes an authority without which the drugs cannot be supplied. It is obviously necessary that, as in the case of drugs supplied by the doctor himself, drugs should not be ordered except for the express purpose of medical treatment. We recommend therefore, that it should be explicitely provided by the Regulations that a prescription for Dangerous Drugs shall not be given except, bona fide, for medical purposes.
77. Secondly, we have been asked to consider the advisability of power being given under the Regulations to the Home Secretary to withdraw the right to prescribe these particular drugs in certain conditions. It is clearly essential, from the point of view of efficient administration, that some meansshould exist whereby a doctor whose authorisation to possess and supply the drugs has been withdrawn might be precluded also from prescribing them in cases where this further step was thought to be necessary. In the majority of cases in which the authorisation to possess and supply had been withdrawn on account of the doctor's improper administration or supplly of the drugs the object of the wthdrawal, as regards protection of the community, would obviously not be achieved if he were still permittedto prescribe.
78. If our recommendation as to the procedure in the matter of withdrawal of authority to possess and supply were adopted the most simple and direct method of dealing with the question of withdrawal of the right to prescribe Dangerous Drugs would be by providing that cases in which this question arose should be referred to the same medical tribunal as as deals with questions of possession and supply and that power should be conferred on the Home Secretary by the Regulations to withdraw the right to precribe in cases in which the Tribunal so advised and we recommend accordingly.
QUESTIONS OF OBLIGATIONS ON PRACTITIONERS (a) TO NOTIFY (b) TO OBTAIN SECOND OPINION
79. We have considered whether certain special obligations should be placed by the Regulations on medical practitioners when engaged in the treatment of persons to whom morphine or heroin is being administred continuously, without other necessity than for the relief of the symptoms of addiction. The possible obligations thus considered are (a) that, of notifying such cases to the Home Office and (b) that of obtaining a second medical opinion in certain circumstances.
80. The primary object of a system of notification would be to enable the Home Office more readily to detect cases in which patients were obtaining, the drug of addiction from two or more doctors concurrently, a practice which not only contravenes the intention of the Acts, but is obviously prejudicial to the best interests of the patient. A requirement of notification would no doubt tend also to diminish doubtfully justifiable supplying or ordering of the drugs. Moreover it would assist practioners to excercise firmer control over their patients and would tend to relieve practioners who were acting in good faith from suspicion, and from the liability to unknown inquiries, which at present are unavoidable.
81. Against these advantages have to be weighed the inherent disadvantages of all forms of notification in impairing the confidential character of the relation of doctor and patient. The objections to notification on this ground have been regarded as outweighed in many other connectionsi by what were deemed by public opinion and by the Legislature to be more important interests of the community and of patienits themselves; but each proposal for extension of this principle
to a new group of cases must be considered on its merits.
82. In the present instance we are not satisfied the benefits of the notification would suffice to outweigh the attendant disadvantages. In abstaining from reccommending such a measure we have had regard to the relative infreqency of morphine or heroin addiction in this country at the present time, to the evidence of decrease of the number of cases since the introduction of legislative restrictions, to the expectation that the further operation of the present restrictions on supply, coupled with greater care by practitioners in the use of the drugs in treatment, may go a long way to exinguish the evil, and to the view expressed by the Home Office that notification, though it would be useful is not essential for detecting persons who obtain drugs of addiction from more than one doctor at a time. At the same time we consider that every practitioner prescribing morphine or heroin for the first time to a patient who does not require the drugs except for the treatment of symptoms produeed by addiction will be well advised, in his own interest and in those of the patient, to make inquiries from that patient as to the source from which he obtained or is at the time obtaining, the drugs in question, and as to the names and addresses of practitioners under whose care he is, or has been.
83. We have considered whether it would be advisable to provide by Regulations that a practitioner should obtain a second medical opinion before consenting to administer morphine or heroin for an indefinite time to a person who does not need them otherwise than for the relief of symptoms of addiction. It has been suggested that this would tend to secure better observance of suitable precautions in the medical use of the drug.
84. We have been impressed by the fact that most of the medical witweses we have heard are of opinion that a second opinion should be obtained in such cases, if practicable, both from the point of view of advantage to the patient, and for the protection of the doctor if his conduct in ordering the drugs should be subsequantly called in question.
85. We do not, however, think it necessary or desirable that any obligation of this kind should be imposed by Regulations. We believe that it will suffice and is eminently desirable that an effort should be made to impress upon the profession generally, the extreme advisabilty of obtaining a second opinion, in these cases and it is conconsidered that this might well be ragarded more or less in the light of a professional obligation, such as is already generally recognised to exist in cases in which certain operations such as the emptying of the pregnant uterus, are contemplated. The evidence including that given on behalf of the British medical Association, justifies the belief that there would be general support in the profession for this proposal.
86. It is understood that in the case of patients who cannot afford the costs of a second opnion, or where there might be difficulty in obtaining such an opnion, the Ministry of Health would be prepared to place the services of their Regional Medical Officer at the disposal of the patient and the practioner if desired.
87.Two alternative measures which we have considered have presented less difficulty, and may be examined more shortly.
RECORDS OF PURCHASES BY NON-DISPENSING DOCTORS.
88. The requirement (referred to in para 17) that doctors who do not dispense drugs should keep a simple record of purchases would doubtless entail a slight burden of book-keeping upon a section of the profession who are at present free. We gather, however, that it would suffice for the purpose if the invoices of such purchases were pasted in order in a book, so as to minimise the work entailed. Doctors who dispense are required to keep a record not only of Dangerous Drugs purchased, but also of those supplied otherwise than by personal administration. Such records facilitate investigation of cases calling for inquiry. In the case of doctors who do not dispense there is at present no corresponding record, and we understand that administration is to some extent hampered in consequence We think the proposed requirement would overcome a defect in the present system which should be remedied in the manner suggested.
COMMUNICATION TO WHOLESALE HOUSES OF NAMES OF DOCTOR-ADDICTS.
89. As a further measure for dealing with the case of the doctor addict, we have been asked to consider whether it would be desirable that a list of such doctors should be supplied to wholesale chemists with a request that they would inform the Home Office of purchases made by doctors on the list. We foresee grave objections to carrying out such a proposal, and do not recommend its adoption.